Children and young people’s experience of psychoanalytic psychotherapy: a qualitative meta-synthesis

ABSTRACT

The development of evidence-based practice guidelines for psychotherapy is based primarily on the findings from randomised controlled trials, but there is also a need to understand and learn from the experience of those who attend therapy. Some studies have begun to examine the experience of children and adolescents who have been in psychoanalytic psychotherapy. However, no investigations to date have synthesised this body of work and drawn clinical implications from this research. Therefore, this study aimed to provide the first qualitative meta-synthesis of empirical studies examining children and young people’s experiences of psychoanalytic psychotherapy. Articles meeting the inclusion criteria (n = 11) addressed treatments taking place in the UK, Scandinavia and Western Europe, and most of them focused on those who were in therapy as adolescents. The overall methodological quality of the studies was high. Based on the qualitative meta-synthesis, four over-arching themes were identified: (1) Children and adolescents learn to navigate their role during therapy; (2) The importance of the therapeutic relationship; (3) Psychoanalytic psychotherapy as a ‘painful’ process; and (4) Perceived impact of psychotherapy varies and is difficult to gauge. Some of the findings were consistent with the literature on adults’ experiences of psychoanalytic therapy, as well as young people’s experiences of other types of therapy. However, the findings also point to certain unique features of psychoanalytic psychotherapy for children and adolescents. The clinical implications of the findings are discussed.

KEYWORDS:

• Psychoanalytic psychotherapy
• child and adolescent psychotherapy
• qualitative methods
• meta-synthesis
• systematic review

Introduction

Since the first systematic review published in 2011, there have been substantial advances in the research evaluating the effectiveness of psychoanalytic and psychodynamic psychotherapy¹ as a treatment for children and adolescents (Midgley et al., 2021), including evidence for work with infants and babies (Sleed et al., 2023). However, efficacy and effectiveness studies only offer one perspective on the psychotherapy process. There is an increasing recognition that psychotherapy needs to be investigated from different perspectives, with qualitative research methods playing an especially important role. Researchers such as Levitt (2015) and Binder et al. (2016), for example, have argued that qualitative studies have a key role to play in investigating the experiential world of clients and therapists. Given that psychotherapy itself is fundamentally about the process of making sense of experience, our approaches to research need to focus on this important element of meaning-making. As such, there is an increasing acceptance of methodological pluralism in psychotherapy research, and an expectation that qualitative studies be part of any exploration of the impact of psychotherapy (Midgley et al., 2014).

Methodological pluralism is especially valuable in the context of treatments for children and adolescents, as the experiences and perspectives of these populations remain widely underrepresented. For instance, many empirical outcome studies – especially the ones with participants under 12 years of age – rely on parents and teachers’ assessments of a child’s well-being, and even the ones that include measures completed by children and adolescents do so using instruments formulated by (adult) researchers (Godfrey et al., 2019). The lack of representation of children and young people’s experience in much psychotherapy research goes against Article 12 of the United Nations (2019) Convention on the Rights of the Child, which sets out ‘every child/young person’s right to have their voice heard in decisions that affect them’. The lack of such a voice in psychotherapy research has contributed to current limitations in our understanding of the treatments offered to children and adolescents. This is reflected, for instance, in the outcome literature overemphasising the importance of changes in symptoms (Krause et al., 2019), and overlooking key criteria seen as important by young service users, such as improvements in relationships with peers and family members, or the capacity to manage better in school (Krause et al., 2020).

The limited representation of children and adolescents’ perspectives in psychotherapy research is a general issue but may be especially important in the field of psychoanalytic psychotherapy, given the importance of subjectivity for this approach (Meissner, 1999). In trying to fill this gap, some authors have made significant contributions to this field. For instance, Fonagy and Target (2002) included a qualitative component to their retrospective study based at the Anna Freud Centre in London, including participants who were in child or adolescent psychoanalysis between 1952 and 1980; and the IMPACT-My Experience (IMPACT-ME) study (Midgley et al., 2014), was a qualitative project embedded into a randomised clinical trial in the UK assessing different psychological treatments for depressed adolescents (Goodyer et al., 2017). However, despite the growing focus on qualitative research in psychoanalytic psychotherapy with children and young people, no systematic review of this literature has taken place.

Rationale for the current study

Until the last ten years, few attempts to systematically review qualitative studies in the field of psychotherapy research have been carried out. Traditionally, the findings of quantitative studies have been brought together in the form of meta-analyses, which involve statistical processes that combine the data of multiple studies to find common results and to identify overall trends. However, it has not been so clear how to bring together the findings from different qualitative studies, given each study is attempting to make sense of the unique experiences of the participants in that particular context. Qualitative meta-synthesis (sometimes referred to as ‘meta-ethnography’ or ‘meta-aggregation’; Sattar et al., 2021) is an emerging approach that analyses and combines data from multiple qualitative studies. This has made it possible to go beyond the findings of individual studies, to begin to identify patterns and themes across multiple qualitative studies.

While there are now several systematic reviews bringing together studies examining adults’ experience of psychotherapy (e.g., Finazzi & MacBeth, 2022; Levitt et al., 2016; Sweeney et al., 2019), including studies that have examined specific client groups, such as those with depression (McPherson et al., 2020), or specific aspects of therapy, such as negative experiences (Vybíral et al., 2023), no studies to date have examined children and adolescents’ experiences of psychoanalytic psychotherapy. Given this context, the aim of the current study was to provide the first qualitative meta-synthesis of empirical studies examining children and young people’s experiences of this type of therapy. Considering this background, the current study has the following aims:

1. Synthesise and appraise the current findings concerning children and young people’s experience of psychoanalytic psychotherapy from qualitative studies drawing on interviews with those who have experienced such therapies;

2. Evaluate the methodological quality of these studies;

3. Draw clinical implications from the meta-synthesis of these qualitative studies.

Methods

This study is a systematic review following the PRISMA guidelines (Page et al., 2021), prospectively registered at PROSPERO (CRD42023394775). In order to synthesise the findings drawn from qualitative investigations, the current study adopted the JBI meta-aggregation approach (Aromataris & Munn, 2020). This approach is particularly aligned with the aims of this study as it not only outlines a systematic way of identifying, evaluating and synthesising qualitative findings but also involves drawing practical and useful implications from primary qualitative data, rather than targeting the re-interpretation of previous findings. Below, we describe the specific methodological steps taken in this study, including the presentation of the specific tools derived from the JBI approach.

Eligibility criteria

The inclusion criteria were:

• Peer-reviewed articles and doctoral dissertations reporting qualitative studies addressing children and/or adolescents’ views or experiences of their psychoanalytic or psychodynamic psychotherapy;

• Studies whose participants attended therapy between the ages of five to 18, even if they were older at data collection (i.e., when interviews took place);

• Studies including participants outside the set age range if the majority and/or mean age of participants were between five to 18 years old.

The exclusion criteria were:

• Psychoanalytic psychotherapy process studies that focused on therapeutic mechanisms other than how the participants experienced their therapy;

• Qualitative studies using a priori coding systems (i.e., which were more focused on testing existing ideas, rather than new learning based on the young person’s experiences);

• Quantitative survey studies (such as feedback questionnaires) about children or adolescents’ experiences of therapy;

• Studies exploring children and adolescents’ perspectives on psychoanalytic therapy which were not based on personal experience as a patient (e.g., studies looking at how children or young people imagined therapy to be, not based on their own experience, including their expectations about a treatment that was about to start);

• Narrative accounts of psychoanalytic psychotherapy (see Heller, 1990; Midgley, 2012) where there was no use of a systematic qualitative methodology;

• Studies that examined children and young people’s experiences of psychotherapy generally (i.e., not specifically psychoanalytic psychotherapy), unless more than half of the young people specifically reported that they had been in psychoanalytic treatment, or else the analysis reported on experiences of psychoanalytic therapy separately.

Information sources

In order to make the search as wide as possible, we consulted the databases PsycINFO, MEDLINE, and Web of Science specifying the date of publication from 1990 to April 2023. Only studies published in English were included. In addition to these database searches, the reference lists of all relevant studies were screened for additional investigations that would meet our inclusion criteria. Additionally, we reached out to psychoanalytic research doctorate programmes and child psychoanalytic training organisations in the UK, to help identify research that could be eligible. The search strategy included a range of terms focusing on the target population (i.e., children and adolescents), the type of intervention (i.e., psychoanalytic psychotherapy), and different aspects of qualitative methods. For the full description of the search strategy, see the supplemental online material.

Selection process

The study selection process and subsequent stages were carried out using the online tool CADIMA (Kohl et al., 2018), used to automate the steps of a systematic review. Five of the authors (GF, MW, RC, MJ, and HN) were involved in the screening of titles and abstracts and full-text screenings. As a first step, all authors rated the same 15 titles and abstracts to calculate their agreement through kappa value, and to identify any possible initial inconsistencies. After the initial consistency check, 10% of the remaining titles and abstracts were rated by two members of the team in parallel, with random pairings considering the five authors mentioned above. The remaining entries were single-rated.

After completing the title and abstract screening, all authors participated in a second stage of consistency check, for the full-text screening, to ensure that the team was reliably applying the inclusion/exclusion criteria to identify eligible studies. In this consistency check, the team rated ten random entries that passed the titles and abstract screening and discussed any inconsistencies. Following this step, all remaining full texts were single-screened by one of the five authors.

Data extraction process and quality assessment

To extract the relevant data from the selected studies, we were guided by the JBI qualitative data extraction tool (Aromataris & Munn, 2020). This tool suggests that researchers should include aspects such as the study’s methodology, phenomena of interest and setting (e.g., country, type of service etc.). Aligned with the scope of the current review, we also included relevant extraction topics, such as the specific type of psychoanalytic psychotherapy (if specified), treatment duration, and time point when data collection took place (i.e., whether this was directly after therapy had ended, or at a later point). Furthermore, this tool also includes a credibility rating for the individual study’s findings, which helps to assess the quality of the study and provides guidance on how credible and trustworthy the findings are. With this tool, each theme described in each study was assessed in terms of its presented evidence being

(1) Unequivocal (i.e., findings that included an illustration that was ‘beyond reasonable doubt’), (2) Credible (i.e., findings with an illustration that lacked clear association with it and therefore open to challenge), or (3) Not supported (i.e., the findings were not supported by the data). The assessments were made independently by the different researchers in the group and revised by the first author (GF). Inconsistencies were resolved by consensus.

Alongside the data extraction and credibility assessment, we also used the JBI qualitative critical appraisal criteria (Aromataris & Munn, 2020). With this tool, each study was appraised in terms of the congruity between stated philosophical perspective and research methodology, between research methodology and research questions, aims, data collection, and interpretation of results.

Synthesis methods

To synthesise the qualitative findings, the first author of this study (GF) familiarised himself with all full texts from all selected papers and developed initial overarching aggregated themes. Then, the other authors (MW, RC, MJ, and HN) held a series of ‘auditing’ meetings, in which each member was responsible for ‘defending’ specific studies and ensuring that the findings were accurately and sufficiently represented in the aggregated themes. Following these meetings, the final themes and their description were developed, reviewed with the supervisor of the project (NM), revised once more and then agreed upon.

Positionality statement

Researchers’ subjectivity plays a role in how studies are carried out and may impact how findings are interpreted (Levitt et al., 2022). Therefore, especially in qualitative studies, it is recommended that authors clarify through what ‘lenses’ the research was undertaken (Holmes, 2020).

In the current study, our team was diverse in terms of our professional and personal backgrounds. While some authors had experience working as therapists and were familiar with the psychoanalytic perspective, others did not have clinical experience nor specific allegiance to psychoanalysis. This was particularly helpful in our group discussions, as we did not want to analyse the data putting psychoanalysis ‘in a good light’ driven by implicit biases. Furthermore, since this study’s focus was on children and young people’s perspectives, it was also helpful to have discussions in a group that was not entirely composed of therapists, who might have a different viewpoint concerning the therapy process. Our group also had members from different regions of the world (including Asia, Europe, and South America) and with different levels of seniority (from research assistant level to full professor level), which was especially valuable in the discussions surrounding how the studies identified addressed their own authors’ subjectivity and reported on their participants’ backgrounds.

Results

Study selection

5322 studies were identified on MEDLINE and PsycInfo (through an integrated Ovid search), 1116 on Web of Science, and 186 doctoral theses from training organisations in the UK (total = 6624). These entries were automatically de-duplicated through EndNote, leaving a total of 5560. These were then uploaded to CADIMA for the subsequent steps.

After the de-duplication of studies, the authors went through a consistency check for titles and abstracts, to ensure that studies were being identified in a systematic and consistent way, reaching a kappa value of .76. After the consistency check, the remaining entries were screened in relation to their titles and abstracts, with 322 moving forward to the full-text screening. Most excluded studies did not focus on psychoanalytic psychotherapies or used a case study approach that did not include data from the child or young person’s perspective. After the full-text screening, 311 studies were excluded, with the remaining 11 being analysed in the current meta-synthesis. A flowchart of the study selection can be found in Figure 1, and a summary of the selected studies following the JBI qualitative data extraction tool is presented in the supplemental online material.

Figure 1. Prisma flowchart.

Study characteristics

All 11 studies identified were carried out in Europe and published between 2005 and 2023. Seven of the studies addressed treatments taking place in the United Kingdom, two in Norway and two in Sweden. Regarding the treatments offered, nine studies investigated children’s and adolescents’ experiences of face-to-face psychoanalytic psychotherapy, while two explored the experience of internet-based psychoanalytic psychotherapy (IPDT). Most studies focused exclusively on adolescents’ perspectives (n = 8), with two looking across both children and adolescents (Midgley, 2006; Midgley & Target, 2005) and only one study focused exclusively on the experience of children in psychoanalytic therapy (Carlberg et al., 2009). While most studies involved data collection within one year of therapy ending, two investigations were retrospective studies, with adults recounting their experiences of psychoanalytic psychotherapy that took place when they were children or adolescents (Midgley, 2006; Midgley & Target, 2005).

The number of participants across the 11 studies ranged from one to 27, with the mean number of participants per study being 11.8. While some papers analysed subsamples of the same large study, only two papers reported on the exact same set of participants (Midgley, 2006; Midgley & Target, 2005). Of the 103 children and young people included across the 11 studies, 22 were reported as male and 64 as female. The gender of the remaining 17 participants was not reported. Ethnicity was not reported in the majority of the studies (n = 8), encompassing 85 cases. For the three papers where ethnicity was reported, one young person was white British and 17 young people were ethnically Norwegian. Concerning the problems that brought the children and young people to therapy, seven studies exclusively focused on cases of adolescents with a major depressive disorder, with three of these based on findings from the same study (IMPACT-ME; Midgley et al., 2014). The four remaining studies included a wide range of problems such as eating disorders, self-harm, disruptive behaviour, social phobia and psychotic problems.

In five studies, participants were offered 28 weekly sessions of short-term psychoanalytic psychotherapy (STPP; Cregeen et al., 2017), delivered by psychoanalytically trained child and adolescent psychotherapists working in Child and Adolescent Mental Health Services (CAMHS) in the UK or Norway (Cirasola et al., 2022; Housby et al., 2021; Løvgren et al., 2019, 2020; Marotti et al., 2020). However, in two of these studies the young people were randomised into different versions of short-term psychoanalytic psychotherapy: one with and one without the use of transference interpretations (Løvgren et al., 2019, 2020). In the two retrospective investigations included, children and adolescents attended either weekly or intensive psychoanalytic psychotherapy (i.e., four to five sessions a week) in the voluntary sector, with treatments lasting between nine months to four years and six months (Midgley et al., 2006; Midgley & Target, 2005). In Carlberg et al.’s (2009) study, psychodynamic psychotherapy was offered to children once or twice a week over a period of one to two years in local mental health services or psychiatric outpatient clinics. Bury et al. (2007) focused on weekly psychoanalytic psychotherapy delivered in a community-based mental health clinic, including adolescents who had been in therapy for at least six months but no longer than 18 months. Finally, two studies addressed the experience of internet-based psychodynamic psychotherapy (IPDT), combining self-guided, online activities and weekly, real-time text-based sessions with a therapist (Lindqvist et al., 2022; MacKean et al., 2023). The two IPDT studies were the only investigations in which the treatment was not delivered by qualified psychoanalytic child psychotherapists, but rather by post-graduate clinical psychology students, with specific training and supervision in this approach.

The qualitative analytical methods employed in the studies reviewed were Interpretative Phenomenological Analysis (IPA, n = 4; Bury et al., 2007; Housby et al., 2021; Marotti et al., 2020; Midgley et al., 2006), thematic analysis (n = 2; Lindqvist et al., 2022; MacKean et al., 2023), content analysis (n = 1; Carlberg et al., 2009), an analysis following the positioning theory (n = 1; Løvgren et al., 2020), systematic text condensation and hermeneutic interpretation (n = 1; Løvgren et al., 2019) and framework analysis (n = 1; Cirasola et al., 2022). One study described its analysis as broadly ‘qualitative’ (n = 1; Midgley & Target, 2005).

Quality appraisal

A summary of the quality appraisal, as assessed through the JBI qualitative critical appraisal criteria, can be found in Table 1. It was notable that all studies demonstrated congruity between their philosophical perspective and research methodology, between their research methodology and research question, aims, data collection, analysis and interpretation of results. All of them included in their reports the voices of their participants, and their conclusions had a logical and justified flow considering the analysis and interpretation of the data.

Table 1. Quality appraisal checklist.

STUDY	Q1	Q2	Q3	Q4	Q5	Q6	Q7	Q8	Q9	Q10	Total (/10)
Bury et al. (2007)	Y	Y	Y	Y	Y	Y	Y	Y	U	Y	9
Carlberg et al., (2009)	Y	Y	Y	Y	Y	N	N	Y	Y	Y	8
Cirasola et al. (2022)	Y	Y	Y	Y	Y	N	Y	Y	Y	Y	9
Housby et al., (2021)	Y	Y	Y	Y	Y	N	Y	Y	Y	Y	9
Lindqvist et al., (2022)	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	10
Løvgren et al. (2020)	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	10
Løvgren et al. (2019)	Y	Y	Y	Y	Y	N	U	Y	Y	Y	8
MacKean et al. (2023)	Y	Y	Y	Y	Y	N	N	Y	Y	Y	8
Marotti et al. (2020)	Y	Y	Y	Y	Y	N	N	Y	Y	Y	8
Midgley & Target (2005)	Y	Y	Y	Y	Y	N	N	Y	U	Y	7
Midgley et al. (2006)	Y	Y	Y	Y	Y	Y	Y	Y	U	Y	9
% YES	100%	100%	100%	100%	100%	36%	55%	100%	73%	100%	95/110

Note: Y = yes; N = no; U = unclear. Q1: Is there congruity between the philosophical perspective and the research methodology?; Q2: Is there congruity between the research methodology and the research question or objectives?; Q3: Is there congruity between the research methodology and the methods used to collect data?; Q4: Is there congruity between the research methodology and the representation and analysis of data?; Q5: Is there congruity between the research methodology and the interpretation of results?; Q6: Is there a statement locating the researcher culturally or theoretically?; Q7: Is the influence of the researcher on the research, and vice-versa, addressed?; Q8: Are participants, and their voices, adequately represented?; Q9: Is the research ethical according to current criteria or, for recent studies, and is there evidence of ethical approval by an appropriate body?; Q10: Do the conclusions drawn in the research report flow from the analysis, or interpretation, of the data?

On the other hand, the studies were not as consistent regarding explicitly locating the researchers culturally or theoretically, with only four studies doing so. Similarly, only six studies commented on the influence of the researcher’s own position or beliefs on the research and/or vice-versa. Three studies were considered ‘unclear’ about carrying out ethical procedures according to current criteria. In our assessment, it did not seem that the studies were unethical per se, but the reports either did not include an ethics statement at all or did not state which specific body approved the investigation.

In addition to the JBI qualitative critical appraisal criteria, we assessed each theme presented in each study according to the JBI qualitative data extraction tool. No finding was rated as ‘unsupported’, indicating an overall good quality in the reporting of the evidence. Moreover, 76 out of the 89 findings (85%) were rated as ‘unequivocal’ in relation to the evidence presented to support them. The full description of this assessment can be found in Table 2.

Table 2. Included findings and credibility rating.

Paper	Finding	Numbered finding	Credibility rating
Bury et al. (2007)	Beginning therapy	1.1	Unequivocal
	Mixed feelings	1.2	Credible
	Therapist’s response	1.3	Unequivocal
	The therapeutic process	1.4	Unequivocal
	Learning the ropes	1.5	Unequivocal
	Facilitative aspects	1.6	Credible
	Power	1.7	Unequivocal
	Endings	1.8	Unequivocal
	Ambivalence	1.9	Credible
	Feelings of separation and loss	1.10	Credible
	Moving on	1.11	Credible
Carlberg et al. (2009),	Children’s post-treatment attitudes regarding psychotherapy	2.1	Credible
	Children’s views of therapeutic effect	2.2	Credible
Cirasola et al. (2022),	‘I didn’t like him. but then I started to trust him … and it all changed’, p960	3.1	Unequivocal
	‘It wasn’t like he did this just because he didn’t want to see me’, p960	3.2	Credible
	‘It kind of hurt’ P960–961	3.3	Unequivocal
	Evidence of positive change, p962	3.4	Unequivocal
	The alliance dynamics and the change process, p962–63	3.5	Unequivocal
Housby et al., (2021)	Therapy as a transformational process, p6–8	4.1	Unequivocal
	‘Just sort of grew on me more’: Adjusting to the therapeutic model, p6–7	4.2	Unequivocal
	‘It transforms you’: Gaining a new perspective, p7–8	4.3	Unequivocal
	Explorative or Exposing: The therapeutic space, p8–9	4.4	Unequivocal
	‘slowly starting to unravel’: An explorative space, p8–9	4.5	Unequivocal
	‘what’s the right answer?’: An exposing space, p8–9	4.6	Unequivocal
	Being Heard and Working Together: the therapeutic relationship, p9–11	4.7	Unequivocal
	‘Being heard’: building trusting relationship, p10	4.8	Unequivocal
	‘we worked a way… to catch it’: working together, p10–11	4.9	Unequivocal
Lindqvist et al. (2022),	A Meaningful and Significant Relationship with Someone Who Cared, p6–7	5.1	Unequivocal
	She knew me, p6	5.2	Unequivocal
	She wanted the best for me, p6	5.3	Unequivocal
	She was a real person, p6–7	5.4	Credible
	A Helping Relationship with Someone who Guided and Motivated me Through Therapy, p7–8	5.5	Unequivocal
	She made me stay and engage, p7–8	5.6	Unequivocal
	She helped me understand myself, p8	5.7	Unequivocal
	She made it about me, p8	5.8	Unequivocal
	A Relationship Made Safer and More Open by the Fact that we Didn’t Have to Meet, p8–9	5.9	Unequivocal
	My information was safe with the therapist, p8–9	5.10	Unequivocal
	Not having to observe and be observed, p9	5.11	Unequivocal
	An Insignificant Relationship with Someone I Didn’t Really Know and Who Didn’t Know Me, p9–10	5.12	Unequivocal
	Not much of a relationship, p9	5.13	Unequivocal
	Her focus was off, p9–10	5.14	Unequivocal
	Distance hindering therapeutic closeness, p10	5.15	Unequivocal
Løvgren et al., (2019)	Exploring oneself, p4–5	6.1	Unequivocal
	Autonomy and acknowledgement, p4	6.2	Unequivocal
	Openness, p4–5	6.3	Unequivocal
	Insight and acceptance of oneself, p5	6.4	Unequivocal
	Therapist relation and characteristics, p5–6	6.5	Unequivocal
	Confidence, trust and support, p5–6	6.6	Unequivocal
	Trustworthy and experienced, p6	6.7	Credible
	Focusing on everyday life, p6	6.8	Unequivocal
	Learning, p7	6.9	Unequivocal
	Practical orientation, p7	6.10	Unequivocal
	Time factors, p7	6.11	Unequivocal
Løvgren et al. (2020),	From conflicted mutuality to friendly mutuality (with no transference interpretations) Storyline: The power of breaking norms, p12	7.1	Unequivocal
	From non-reciprocal mutuality to self-focused mutuality (with no transference interpretations) Storyline: Putting oneself in the foreground, p13–14	7.2	Unequivocal
	From verbal mutuality to tragic mutuality (with no transference interpretations) Storyline: Striving for concrete guidance, p14–15	7.3	Unequivocal
	From agreed mutuality to disempowered mutuality (with transference interpretations) Storyline: The primacy of the body, p15–16	7.4	Credible
	From awaited mutuality to restrained mutuality (with no transference interpretations) Storyline: About normality, not psychiatry, p16–17	7.5	Unequivocal
	From quiet mutuality to conversational mutuality (with transference interpretations) Storyline: Different types of questions, p17–18	7.6	Unequivocal
	From robust mutuality to solo mutuality (with no transference interpretations) Storyline: Allowing negativity, p18–20	7.7	Unequivocal
	From mechanical mutuality to robotic mutuality (with no transference interpretations) Storyline: A decent drop out, p20–22	7.8	Credible
	From unclear mutuality to pseudo mutuality (with transference interpretations) Storyline: Unimproved but safer, p22–23	7.9	Unequivocal
MacKean et al. (2023)	‘Weird sort of friendliness with someone you’ve never met before’: strong therapeutic relationship, p8–9	8.1	Unequivocal
	‘You didn’t have someone there staring into your soul’: less intimidating. p8–9	8.2	Unequivocal
	‘I saw her as a friend almost’: TSW as an equal, p9	8.3	Unequivocal
	‘you have to sort of like give your all time to it’: significant commitment, p9–10	8.4	Unequivocal
	‘For someone who doesn’t really engage … it wouldn’t work at all’: motivation needed, p9–10	8.5	Unequivocal
	‘I probably would have given up’: therapeutic relationship essential, p10	8.6	Unequivocal
	‘Helped me on my journey to cope better’: facilitated change, p10–11	8.7	Unequivocal
	A personalised psychoeducation, p11	8.8	Unequivocal
	‘I feel in more control of my emotions’: skills gained, p.11	8.9	Unequivocal
	‘it’s way better than I thought it would be’: gained appreciation’, p12–13	8.10	Credible
Marotti et al. (2020),	Pain in therapy for a worthwhile process, p407–408	9.1	Unequivocal
	A painful process of self-disclosure, p407–408	9.2	Unequivocal
	‘If you can understand something you can fix something’, p408–409	9.3	Unequivocal
	A relationship unlike others: Creating a space for reflection, p408–409	9.4	Unequivocal
	An understanding, accepting and non-judging relationship, p408–409	9.5	Unequivocal
	The therapist is unlike others, p409–410	9.6	Unequivocal
	Ending therapy with ‘a little bit of a relief and a little bit of hope’, p410	9.7	Unequivocal
	‘Hope I fit everything in’: A wish for more therapy, p410	9.8	Unequivocal
	Finding meaning in therapy, p410–411	9.9	Unequivocal
Midgley et al. (2005),	Attitudes towards being in therapy, p162–163	10.1	Unequivocal
	Memories of therapy and the therapist, p165–171	10.2	Unequivocal
Midgley et al. (2006),	If it did help me, I’m very grateful but – how do I establish that … ?, p 261	11.1	Unequivocal
	Like the BT advert, it’s good to talk, p261–262	11.2	Unequivocal
	I haven’t really changed, but my ability to cope with it has changed, p262–263	11.3	Unequivocal
	The tools for self-analysis, p263–264	11.4	Unequivocal
	I wasn’t at all sure that it was doing any good, p264	11.5	Unequivocal
	I think it really made things worse, p264–265	11.6	Unequivocal

Study synthesis

Following the data analysis and synthesis steps described in the methods, four synthesised themes were developed, as described below. Figure 2 shows what specific themes from the original studies contributed to each synthesised finding in this meta-synthesis. Selected data extracts from interviews with participants in the original studies are included to give a clearer sense of the themes of the meta-synthesis.

Figure 2. Themes in each synthesised finding.

Synthesised theme 1: children and adolescents learn to navigate their role during therapy

The meta-synthesis suggests that uncertainty was a common theme across the children and young people’s experiences, especially surrounding their understanding of the nature of their role within therapy and the purpose of being in treatment (Bury et al., 2007; Housby et al., 2021; Lindqvist et al., 2022; Løvgren et al., 2019; Marotti et al., 2020; Midgley & Target, 2005). In particular, some young people seemed unprepared for therapy, often describing their feeling that they did not have a choice or know why they were attending therapy: ‘at eleven I didn’t have any choice about going. I didn’t choose to go and it was never explained’ (Midgley & Target, 2005, p. 163). Young people spoke about entering therapy not knowing what to expect, and some expressed feeling confused by the therapist’s queries and observations – without understanding why the therapist was asking certain types of questions: ‘I would be playing with a doll … and then I would think, “why are they asking me this?”’ (Midgley & Target, 2005, p. 170).

The interplay between navigating the role of a child or young person in therapy and understanding the treatment’s boundaries was reported by quite a few participants in the studies reviewed. In some cases, young people spoke about their wish to ask the therapist questions about their personal lives and interests, but often decided not to ask questions to avoid being seen as ‘intrusive’ or ‘rude’. Being perceived as a ‘good patient’ or liked by the therapist also seemed to be important to some children and young people, with some ‘testing the limits’ of what could be shared in therapy: ‘Before I said something, I kind of thought, … will this put me in a bad light?’ (Løvgren et al., 2020, p. 247). Interestingly, children and adolescents seemed to have their own ideas about what a therapist was or wasn’t ‘allowed’ to do in sessions, although they didn’t necessarily show an awareness of why this was quite the case: ‘It’s so often you can get that, like … “What about you? How are you?” They are not supposed to answer that; that’s not the way it works’ (Løvgren et al., 2020, p. 246).

The uncertainty surrounding what was expected from them in therapy, and why certain things did (or did not) happen, was something that studies reported as being resolved for some young people over time as the sessions progressed: ‘I finally started getting the hang of it, I’d just say the first thing that came into my head’ (Bury et al., 2007, p. 87). However, learning how to navigate therapy was largely described as a self-taught process: ‘I feel that basically, it is you yourself who has to do it’ (Løvgren et al., 2020, p. 244). This extract reflects the sense that young people felt that it was up to them to work out the ‘rules’ of therapy and to decide what they would share and what they would hold back.

Overall, the studies indicate that children and young people described mixed perceptions and experiences of navigating psychoanalytic therapy, especially in the early stages of treatment. However, the studies also highlighted the way in which being in psychotherapy was experienced as something quite different to other settings for many children and young people; one where there was a great deal of uncertainty, but also a sense of freedom for them to decide how that space should be navigated.

Synthesised theme 2: the importance of the therapeutic relationship

All articles reported findings demonstrating the importance of children and young people’s experience of the therapeutic relationship during psychoanalytic psychotherapy. The data covered some features that seem to be appreciated in the relationship and other features that might lead to less positive experiences of therapy. This synthesised theme is organised into the following subthemes: (1) The value of a warm, understanding, and caring therapist; (2) A different kind of relationship: the value of a non-judgemental, accepting and encouraging therapist; (3) The importance of a therapist who is an expert and competent guide; and (4) The therapeutic relationship in online therapy.

Subtheme 2.1: the value of a warm, understanding and caring therapist

According to the studies included, children and young people valued a warm therapist whom they could trust, was felt to be understanding and perceived as someone who genuinely cared about them (Bury et al., 2007; Cirasola et al., 2022; Housby et al., 2021; Lindqvist et al., 2022; Løvgren et al.,2019, 2020; MacKean et al., 2023; Midgley & Target, 2005). Feeling cared about seemed to be particularly important when children and young people felt they did not have other genuinely caring relationships in their lives: ‘[I felt] kind of special (…) because back then I felt like nobody cared about me and I think it made me feel good within myself because it was just, it’s kind of what I needed to feel’ (Cirasola et al., 2022, p. 962). In the investigations, children and young people also spoke about the importance of feeling understood through their therapist’s validation of their suffering, especially when it was accompanied by the reassurance that they could talk about it and work through the difficulties.

Children and young people also felt more at ease when their therapist seemed to understand their perspective and respected their boundaries: ‘if I talked about something I preferably would not like to talk about, she talked about it indirectly and let me know that she understood what I was talking about. (…) It became as if, like, she understood that if someone took the theme up, it would be me’ (Løvgren et al., 2020, p. 246). This reflects that patients appreciated therapists who would follow their pace when discussing some issues.

When therapists did not show these characteristics, participants reported challenges with the therapeutic relationship, and this was especially true among adolescents. Young people in different studies described feeling uncomfortable when their therapist did not understand them, did not appear to recognise when they were talking about an important topic, or just stayed silent: ‘it was really awkward coz like I-I just we’d spent the whole time just sat there saying nothing’ (Housby et al., 2021, p. 7). If young people felt misunderstood and dismissed, they described therapy as being less helpful in overcoming their difficulties.

Subtheme 2.2: a different kind of relationship: the value of a non-judgemental and accepting therapist

Many participants reflected on their perception that therapy created a unique space for conversation, which was different from relationships with other figures: ‘it’s something quite different than talking to a friend or a mother or father, because then it becomes (…) very comforting’ (Løvgren et al., 2020, p. 247). In that context, they perceived that not being judged fostered a safe space to discuss their issues in a new context. This feeling of safety led to young people feeling accepted, comfortable and at ease with their therapists. Hence, the studies indicate that therapy might have been seen as a new relational opportunity, allowing young people to authentically express themselves.

This type of relationship was seen as taking time to develop and might depend on certain factors. Young people sometimes described a sense of fear that their therapist would judge them and described how their trust in the therapist evolved gradually across the course of therapy, in response to some ‘testing’ of the therapist’s reactions: ‘In a way I tested the limits of what I could say without being afraid of being judged’ (Løvgren et al., 2019, p. 5).

Subtheme 2.3: the importance of a therapist who is an expert and competent guide

The meta-synthesis of findings from these studies suggests that children and young people valued a therapist who was friendly and kind, but that they did not want the therapist to be the same as one of their peers. For some of them, it was also important that the psychoanalytic therapist was experienced as someone who was ‘educated’ and an ‘expert’ (Bury et al., 2007; Housby et al., 2021; Lindqvist et al., 2022; Løvgren et al.,2019, 2020; Marotti et al., 2020). This contributed to greater levels of trust in the therapist’s skills to actively guide them and provide ‘concrete suggestions’ in order to progress. Therapists were felt to ask probing questions that were seen as helpful such as ‘what did this do to you?’ (e.g., Løvgren et al., 2020, p. 247). These were questions, sometimes quite challenging, that young people recognised they may not have been asked in other contexts. These questions were experienced positively when they gave the young people a sense that the therapist ‘just wanted to understand [the situation] better’ (e.g., Marotti et al., 2020, p. 409), rather than change their mind, or judge them for their actions. They found it particularly helpful when therapists took the time to ‘work it out’ together, as it felt like the therapist was really ‘taking in’ what they were saying.

However, several studies described participants who voiced a sense of inferiority which seemed exacerbated by a perceived imbalance of power between the therapist and themselves. The specific relational features of therapy, with the child or adolescent opening up but often not knowing much about their therapist felt ‘strange’ for some young people. In that regard, some adolescents reported feelings of the therapist ‘knowing everything’ about them, while they ‘knew nothing’ about their therapist, and that this was problematic. Some young people spoke about how they would have felt more supported if their therapist allowed the relationship to be more ‘two-way’ (e.g., by sharing more about themselves or answering some of the young person’s questions).

Subtheme 2.4: the therapeutic relationship in online therapy

Especially since the COVID-19 pandemic, many psychotherapies had to adapt to being delivered online, including via telephone or online (Bate & Malberg, 2020). None of the studies in this meta-synthesis reported on children or young people’s experiences of teletherapy or video-based sessions, but two articles specifically focused on adolescents’ experiences of online therapy where the weekly sessions took place via a text-based chat function, where the young person and therapist interacted via text (Lindqvist et al., 2022; MacKean et al., 2023). The findings presented in these papers significantly coincided with themes from the studies reporting on face-to-face psychotherapy. In that sense, as described in the previous sub-themes, having a therapist who was perceived as warm, understanding, caring and took a non-judgemental and accepting stance was appreciated by adolescents also in online, text-based interactions. However, there were some differences.

Online therapy via a text-based chat (as opposed to sessions delivered via Zoom or Microsoft Teams) seemed to make the therapeutic relationship feel safer for some adolescents, compared to their own prior experiences of face-to-face therapy. At times, young people directly linked this to the perceived shift in the power dynamic when using a text-based chat function, which was felt to be less intimidating for some compared to sitting in a room with a therapist or looking at their face, or on a screen. They spoke about how the text-based chat format felt less intense, which for some young people was a positive experience, giving them a sense of space and time to think through what they were saying to their therapist, via the chat. For example, one young person spoke about gradually disclosing some painful experiences via chat, which she felt would have been impossible for her to do if the therapist had been there looking at her (Lindqvist et al., 2022). Young people also spoke about feeling able to express themselves more freely compared to if the therapy was in person: ‘with a person sitting close to you, it can get consequences in a way, how much you tell or how little you tell’ (Lindqvist et al., 2022, p. 8). Some also described feeling safer to express emotions as the therapist could not see them, and similarly, they did not have to see or worry about the therapist’s reaction: ‘it felt quite nice because like normally I don’t really open up to people but I had no clue who this person was’ (MacKean et al., 2023, p. 8).

Despite describing generally positive experiences of the therapeutic relationship via text-based chat sessions, children and young people also discussed some limitations. Some young people described how they did not feel like they knew their therapist. While some felt that this actually allowed them to ‘open up’ more, for others the fact they would never meet or directly see their therapist felt ‘weird’ and in the absence of face-to-face sessions, online, chat-based sessions could feel ‘a bit robot-like’ (Lindqvist et al., 2022, p. 10). For some, the online text chat was seen as a barrier to conversation.

These findings suggest that although there are many similarities in how the therapeutic relationship is experienced in online therapy, some young people identified positive advantages to this way of working, while others felt that it would be easier to bond with a therapist when meeting in person.

Synthesised theme 3: psychoanalytic psychotherapy as a ‘painful’ process

The meta-synthesis demonstrated that many participants across the studies included in this review found parts of the psychoanalytic psychotherapy process challenging and/or emotionally painful (Bury et al., 2007; Cirasola et al., 2022; Housby et al., 2021; Løvgren et al., 2019; MacKean et al., 2023; Marotti et al., 2020; Midgley & Target, 2005). This seemed to be the case in two main aspects: the initial process of opening up and feeling exposed at the start of therapy; and then experiences during later stages of therapy around talking about emotions, memories, and thoughts that may be difficult to process.

Many participants described the act of ‘opening up’ about their experiences when starting therapy as challenging, finding that sharing their true feelings was an exposing experience which left a sense of vulnerability: ‘I did find that hard to be relaxed and able to say stuff that I was feeling’ (Bury et al., 2007, p. 88). However, for most participants, the awkwardness and initial hesitancy were reduced over time.: ‘I usually find it hard to open up. But after like three weeks, it felt (…) safe. I could say exactly how I felt without having to feel like (…) a problem’ (Lindqvist et al., 2022, p. 6).

Many of the participants reflected that psychotherapy would bring to the surface emotions, memories, and thoughts that they found challenging to process. For a few of them, this aspect of psychoanalytic therapy was perceived as detrimental in itself: ‘[The therapist] wanted me to dig up old memories and say a lot negative things about family members. In one way, I felt he made things worse’ (Løvgren et al., 2020, p. 243). As this young person’s experience highlights, in some cases being invited to ‘dig up’ difficult emotions sometimes was experienced as making things worse.

In contrast, other participants found acknowledging challenging memories and feelings was a critical part of their therapeutic process: ‘It was something that I tried to keep deep inside of me. And then, I was not allowed to do that. And that was very relieving, in a way being forced to really feel it’ (Løvgren et al., 2019, p. 4). Moreover, the painful feelings were also perceived by some young people as an indication that the therapist had helped the young person reach an important point in understanding their suffering: ‘It was kind of a roller-coaster (…) in the beginning, it was just scratching the surface (…) and then there’s a period where you’re feeling really awful which is kind of when you’ve hit the spot of whatever it was that’s causing it’ (Bury et al., 2007, p. 87). The roller coaster metaphor could illustrate the emotional process young people experience in psychoanalytic psychotherapy, with ‘higher’ and ‘lower’ points experienced on the journey towards understanding themselves better or improving their wellbeing.

Synthesised theme 4: perceived impact of psychotherapy varies and is difficult to gauge

In nearly all studies, children and young people spoke about their perspectives on the impact of therapy on themselves and their lives in general (Carlberg et al., 2009; Cirasola et al., 2022; Housby et al., 2021; Løvgren et al.,2019, 2020; MacKean et al., 2023; Marotti et al., 2020, Midgley et al., 2006; Midgley & Target, 2005). At one end of the spectrum, some participants described a positive impact of therapy in their lives: ‘my life would have been totally different if I hadn’t had therapy’ (Midgley et al., 2006, p. 264). On the other end, participants described harmful impacts of therapy (‘I just developed a fear that I was mad’; Midgley et al., 2006, p. 264) or no significant impact (‘therapy isn’t gonna be able to help me much and I’m just gonna have to be able to help myself’; Marotti et al., 2020, p. 411).

Some participants had a more mixed understanding about the impact of therapy: ‘Even though I’ve often felt that I didn’t achieve anything in that therapy, I was always told, “You are allowed to be who you are.” That is very cool to keep in mind’ (Løvgren et al., 2019, p. 5). Moreover, some participants found it quite hard to measure or gauge the impact of therapy, given they couldn’t know what might have been different if they hadn’t been in therapy. This is illustrated by one participant who was interviewed as an adult several years after their child analysis: ‘If it did help me, I’m very grateful but – how do I establish that, because, unless there was a second clone of me sitting next to me that didn’t come, I don’t know if it’s changed me, or not changed me’ (Midgley et al., 2006, p. 261).

When elaborating on the perceived impact of therapy, participants spoke about different domains of their lives that therapy had an impact on. Firstly, some children and young people spoke about how therapy helped them to gain insights and have a better understanding of themselves (‘most of the time I would sit there goin’ do you know what, that makes sense why I did that’; Housby et al., 2021, p. 7) and their mental health concerns (‘she just like pieced together like my main problems and why my brain has like breakdowns and stuff … it was mind-blowing’; MacKean et al., 2023, p. 11). Secondly, participants spoke about how therapy helped them to evaluate their thoughts and feelings from a more reflective perspective as well as to actively change problematic thoughts and feelings: ‘If I in a way now get a kind of negative thought, I know what to do with it.’ (Løvgren et al., 2019, p. 6). Finally, participants spoke about how therapy led to changes in the way they acted and communicated outside of therapy, in areas of work, study and their interpersonal relationships: ‘In one way, it helped me to take actions, speak up, do this-do that, and stop paying attention to things’ (Løvgren et al., 2019, p. 4).

Some of those interviewed seemed to feel that therapy helped them gain insight into their difficulties, but that this wasn’t always sufficient in itself. This might have led to difficulties in what to do with that insight, or perhaps how to translate insight into action. For some participants, the focus on insight actually made them feel more separate from their peers, or increased their sense of being different to others, while others experienced the focus on making sense of their difficulties as condescending: ‘I know full well what my problems are and what causes them, to have to sit in front of someone who’s (…) trying to dig deeper than that, it feels like I’m being patronised’ (Marotti et al., 2020, p. 408). Some adolescents described the same aspect of therapy more positively and specifically linked insight to solutions which they felt were a benefit of therapy: ‘If you can understand something you can fix something that’s my motto, so if I can understand, like in a computer game, if I can understand why it’s not working I can fix the problem’ (Marotti et al., 2020, p. 408).

Discussion

The current study aimed to perform a meta-synthesis of qualitative studies exploring children and young people’s experience of psychoanalytic psychotherapy. Following a systematic literature search, 11 studies were included, and then assessed in relation to their overall quality using a standardised tool and their findings synthesised. In this discussion, we present and interpret the findings in relation to the broader literature, as well as draw possible clinical implications.

The first synthesised theme ‘Children and adolescents learn to navigate their role during therapy’ described the young people’s feelings of uncertainty about different facets of psychotherapy, including the experience of starting therapy, working out how psychoanalytic therapy is supposed to work, and how they should behave in the setting. Interestingly, this theme has not been extensively found in the adult literature. Although the meta-synthesis conducted by Lavik et al. (2018) raised this as a tentative theme (‘Overcoming initial fears and apprehension about psychotherapy’), the authors highlighted that this was drawn from only one study out of the 15 included in their analysis. In the present review, six out of the 11 studies informed this theme, suggesting that this is a topic more commonly found in children and adolescents’ reports about attending psychoanalytic psychotherapy.

It is widely reported in the literature that children and adolescents are most commonly referred to psychoanalytic therapy by their parents, schools, or other sources rather than seeking it out spontaneously (Logan & King, 2001). Hence, it is possible that the difficulties in opening up and the feelings of ‘learning the ropes’ of psychoanalytic psychotherapy might be exacerbated in this age group. Added to the differences because of age, there might be some specifics of children and adolescents’ experience of psychoanalytic psychotherapy. For example, in two meta-syntheses focusing on cognitive-behavioural therapy (e.g., McCashin et al., 2019; Neelakantan et al., 2019), no superordinate theme identified this type of experience. This might indicate that these feelings of uncertainty during psychotherapy might be more pronounced in psychoanalytic therapies in comparison to other approaches. In psychoanalytic psychotherapy, there may be a less explicit focus from the start on explaining how therapy works, and instead, the young person is invited to gradually discover for themselves what it means to be in therapy. As Cregeen and colleagues put it, when describing the opening phase of short-term psychoanalytic psychotherapy, ‘Unlike more structured approaches to psychotherapy, the initial sessions of STPP should be more like a “process” than a “procedure”’, where ‘the focus is on examining the anxiety and ambivalence often associated with a request for help’ (2017, p. 90). For younger children, the findings of the meta-analysis indicate that not fully understanding why they were in therapy, or how therapy was supposed to work, was less of a worry, as long as the relationship with the therapist was good; for adolescents, however, the findings raise a question about whether this is a necessary element of psychoanalytic therapies, or whether there is a greater need to help prepare young people for starting psychoanalytic psychotherapy. For example, in one study directly comparing different types of psychotherapy for depressed adolescents, the mean ratings of therapeutic alliance in psychoanalytic psychotherapy were rated lower than other approaches, especially in the early phases of treatment (Cirasola et al., 2021). It could be that the uncertainty experienced by young people in the psychoanalytic psychotherapy process might partially explain their lower early-phase alliance levels. The therapeutic alliance is a construct that encompasses the dyads’ bond but also their collaboration on tasks and working towards a goal (Bordin, 1979). In that context, psychoanalytic psychotherapy might be less explicit in setting out its tasks and goals with the young person (Cirasola & Midgley, 2023), leading to feelings of having to ‘learn the ropes’ as they go along.

The second synthesised theme ‘The importance of the therapeutic relationship’ drew on findings from all 11 studies, making it the most prominent theme in the meta-synthesis. Many of the selected studies indicated that children and adolescents appreciate a therapist who is warm, understanding, and conveys a sense that they ‘care’. This seems to be what might be called a ‘common factor’ across different types of therapy (Cuijpers et al., 2019) and is consistent with the experience of adult patients in various types of therapy (Cornelius-White et al., 2018; Finazzi & MacBeth, 2022; Lavik et al., 2018; Levitt et al., 2016). While the literature on children and adolescents attending other types of therapy is scarcer, a meta-synthesis on trauma-focused CBT for children and adolescents found similar themes (‘Therapy as a place of refuge’ and ‘Therapist role and characteristics’; Neelakantan et al., 2019), as well as other individual qualitative studies focusing on CBT (e.g., ‘Developing a therapeutic relationship – a model for real life’ in Donnellan et al., 2013; and ‘Clinician support’ in; Lenhard et al., 2016). Within the psychoanalytic literature, there is a considerable emphasis on the importance of working with the ‘negative transference’ and supporting the emergence of the young person’s more negative and hostile feelings in relation to the therapist; however, this did not seem to prevent young people emphasising that, when therapy was experienced as helpful, the therapist was seen as a largely benevolent figure.

While young people spoke about the importance of therapists being kind and friendly, they saw this relationship as different to the ones they might have with friends or parents. Young people spoke about how therapists took a ‘professional’ or ‘expert’ stance, although this could be experienced in different ways. In some cases, this position seemed to promote a better sense of trust in the therapist; but in others, the ‘professional’ therapist was seen as distant or patronising. This is somewhat different from the findings from meta-analyses of adults’ experiences of psychoanalytic therapy, where therapists’ ‘professionalism’ is described as a feature that allows the patient to be open in the session and make sense of their experiences, with no ‘risks’ or downsides described with this stance (Cornelius-White et al., 2018; Finazzi & MacBeth, 2022). This professional/expert stance might be particularly complex in child and adolescent psychotherapy, where the age difference and power dynamics between therapist and patient are more accentuated.

Online psychoanalytic therapies are still relatively unexamined, especially those where the interaction between young people and therapists is conducted entirely via text-based chat. Overall, just like in face-to-face treatments, the findings of this meta-synthesis suggest that young people appreciate online therapists who are friendly, non-judgemental, and make them feel cared about (Lindqvist et al., 2022; MacKean et al., 2023). Hence the relationships formed in online psychoanalytic psychotherapy seem to feel as ‘real’ to many young people as face-to-face treatments (Midgley et al., 2023). Perhaps texting rather than looking at the therapist brings us back to the use of the couch in classical psychoanalysis, where the patient is not able to see their analyst, and therefore is more able to project aspects of their own internal world onto the therapist. This subjective experience of the therapeutic relationship also seems to influence outcomes, with preliminary data indicating that the therapeutic alliance in internet-based psychodynamic therapy is a mechanism of change in treatments for depressed adolescents (Lindqvist et al., 2023).

Despite the similarities between the experiences concerning the relationship in online and face-to-face psychotherapies, the findings of the meta-synthesis also indicate that there are some key differences in how the therapeutic relationship is perceived by young people. On the one hand, some adolescents reported that a therapeutic relationship with someone only known via text-based chat felt ‘weird’ or ‘robot-like’, preferring to meet a therapist in person, where possible. However, other young people appreciated the sense of anonymity that the text format of IPDT promoted (Lindqvist et al., 2022; MacKean et al., 2023). Although only two studies in this meta-analysis were based on young people’s experiences of IPDT, the findings suggest that online psychoanalytic psychotherapy could be seen as a novel alternative that caters for some young people, not necessarily as a substitute for face-to-face modalities (Midgley et al., 2023).

The third synthesised theme, ‘Psychoanalytic psychotherapy is a painful process’ highlights features of psychoanalytic treatments that might be challenging or emotionally painful for children and young people. The experience of ‘exposing’ oneself to a professional was seen as challenging, at least in the initial sessions. This is a finding reported in previous reviews including children, adolescents, and adults attending different treatment modalities (e.g., Lavik et al., 2018; Levitt et al., 2016; Neelakantan et al., 2019).

In addition to the discomfort of ‘opening up’, children and adolescents also seemed to find it difficult to bring painful feelings to the surface during the psychoanalytic therapy process. While this part of the therapy process is acknowledged by adults (Levitt et al., 2016), it seems to be generally understood as a necessary part of the process of change in psychoanalytic therapies. While some individual qualitative studies of the experience of CBT for adolescents have not reported on this topic (e.g., Lenhard et al., 2016), a meta-synthesis on trauma-focused CBT indicated some similarities to these results (Neelakantan et al., 2019). According to Neelakantan et al. (2019), adolescents attending trauma-focused CBT tended to have more negative views about the therapy when clinicians pressured them to discuss traumatic events and failed to acknowledge the young people’s discomfort in these moments.

The final synthesised theme, concerning the perceived impact of psychotherapy, indicates how difficult it can be for children and young people to know whether any changes they experience are due to psychotherapy or other factors in their lives, or how things may have been different if they had not attended therapy. There appeared to be particularly complex views about the role of increased insight, which has been traditionally considered one of the aims of psychoanalytic therapy (Messer & McWilliams, 2007). While some studies have identified how young people value the sense of increased insight that therapy has provided, in other cases this was seen as less helpful.

With regards to the areas of functioning that young people spoke about being impacted by their experience of therapy, it is striking that young people do not only speak about symptomatic change, but also the impact on the sense of self and relationships. This is in line with the stated aims of psychoanalytic therapy (e.g., Cregeen et al., 2017), as well as previous research on the outcomes of therapy that matter to young people, which are often broader than what is captured in outcome studies using standardised questionnaires (Krause et al., 2020). The meta-synthesis also suggested that the perceived impact of therapy might be linked to the young people’s expectations of therapy, suggesting a need for greater attention to be paid to what young people are hoping for and expecting before starting therapy (Midgley et al., 2016).

Strengths and limitations

Despite the overall high quality of the studies included in this review, some limitations should be highlighted. Firstly, the number of studies of children and young people’s experiences of psychoanalytic therapy is relatively small, and all studies were carried out in Western Europe, including the UK and Scandinavia. The large majority of studies only focused on the experience of adolescents, and out of these, the majority looked at the therapeutic experiences of adolescents with depression. It is unclear whether similar experiences would be found among young people with a broader range of presentations, or those in other geographic regions with differing social and economic backgrounds (Henrich et al., 2010). This is particularly relevant when we consider that most of the studies did not report their participants’ ethnicity, nor the impact of the researchers’ cultural and theoretical standpoint in the interpretation of their findings.

Finally, the majority of the studies used ‘opportunistic’ sampling, (i.e., included children and young people who were available and agreed to be part of the study), and in some cases (e.g., Bury et al., 2007) therapists had a role as ‘gatekeepers’, which may have led to young people with more negative experiences of therapy being excluded. Only three studies (Housby et al., 2021; Løvgren et al., 2019; Midgley et al., 2021) used purposive sampling, all focusing on the experience of ‘good outcome’ therapies and no studies specifically examined the experience of young people with poor outcomes or those who had dropped out of treatment. Therapists seem to refrain from reporting on psychotherapy ‘failure’ (Krivzov et al., 2021), hence further qualitative research addressing this issue might shed light on specific experiences related to this phenomenon. Nevertheless, the relationship between the experience of therapy and treatment outcome is not straightforward; tentative findings have indicated that a ‘good experience’ of psychotherapy might not necessarily lead to positive outcomes, and vice versa (Fiorini et al., 2023; McElvaney & Timulak, 2013). Future qualitative studies might benefit from reporting on quantitative or standardised information about their participants (such as clinical outcome measures), ‘bridging’ the findings drawn from the participants’ lived experience with the ones reported in larger scale studies.

Conclusion

This study was the first systematic review and meta-synthesis of the experience of psychoanalytic psychotherapy among children and young people. Although the number of identified studies was relatively small (11), study quality was generally good. Some clear differences were identified in the four synthesised themes when compared to studies of the experience of children and young people accessing other types of therapy, as well as compared to adult experiences of psychoanalytic psychotherapy. In line with Article 12 of the UN Charter, stating ‘every child/young person’s right to have their voice heard in decisions that affect them’, it is essential that the practice of psychoanalytic psychotherapists working with children and young people is informed by these findings. Researchers should also ensure that the voices of younger children, as well as those from different cultural backgrounds, are included in future studies, as well as the voices of those who may have had poor outcomes or dropped out of therapy.

Patient anonymisation statement

Potentially personally identifying information presented in this article that relates directly or indirectly to an individual, or individuals, has been changed to disguise and safeguard the confidentiality, privacy and data protection rights of those concerned, in accordance with the journal’s anonymisation policy.

Glossary

Content analysis - A qualitative research tool used to determine the presence of certain words, themes, or concepts, commonly used in text/verbal data.

Framework analysis - A qualitative research approach that uses systematic steps to review large amounts of data (usually in text/verbal format) under pre-defined categories.

Hermeneutic interpretation - An interpretative approach that emphasises that what is learned from personal experience also impacts the formal research methods, especially in qualitative research.

Interpretative phenomenological analysis - A qualitative research approach that has as its focus the understanding of participants’ subjective experiences and the meaning they attach to these experiences.

JBI meta-aggregation approach - A specific guideline on how to perform a meta-synthesis.

Kappa value - A measure to investigate if the agreement of two assessments is independent. In systematic reviews, it is used to investigate if different researchers agree that a given study should be included or excluded from the review.

Meta-analysis - A type of systematic review that examines the effect of a treatment and/or intervention in quantitative (i.e., numeric) terms.

Opportunistic sampling - A method of selecting participants in which the researcher recruits individuals based on their availability to take part in a study.

Positioning theory - A type of theory that informs some qualitative analyses and understands that people carry in their lives normative ideas about thinking, feeling, acting, and perceiving. In the context of psychotherapy, both patient and therapist will have their own subjective normative ideas, and their encounter will create unique dynamics, influencing what ‘positions’ they will occupy in the relationship.

Purposive sampling - A method of selecting participants in a study in which the researcher selects a specific group of individuals based on pre-defined criteria to answer a specific question (e.g., selecting only participants who had male therapists).

Qualitative research - A research approach that seeks an in-depth understanding of social phenomena, often involving investigating individuals’ subjective experience on a given topic. Usually implicates working with text/verbal data.

Qualitative meta-synthesis - A type of systematic review that examines findings from previous qualitative studies.

Quantitative research - A research approach that seeks to collect and analyse numerical data. It can be used to find patterns and averages, make predictions, test causal relationships, and generalise results to wider populations.

Randomised controlled trial - A type of study in which several similar people are randomly assigned to two or more groups to test the effect of a specific drug, treatment or other intervention. It examines possible relationships of cause and effect.

Systematic review - A type of literature review that uses repeatable and standardised steps to find, select, and synthesise all available evidence on a given topic and/or answer a specific question.

Systematic text condensation - A qualitative research approach that specifically focuses on cross-case analysis, following specific pre-defined steps.

Thematic analysis - A qualitative research approach that is usually applied to text/verbal data. It examines the data to identify common themes, topics, ideas and patterns of meaning.

Disclosure statement

NM is a psychoanalytic child psychotherapist and was an author of some of the papers included in this review. The other authors have no conflicts of interest to declare.

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/0075417X.2024.2349225.

Additional information

Funding

The work was supported by the Association of Child Psychotherapists (ACP).

Notes on contributors

Guilherme Fiorini

Guilherme Fiorini has a PhD in psychoanalytic studies (University College London, UCL). He is a research officer and research tutor at Anna Freud/UCL. His research focuses on psychological treatments for children and adolescents, especially investigating what client characteristics and therapy features relate to outcomes.

Meryl Westlake

Meryl Westlake is a PhD researcher at University College London and Anna Freud. Her mixed-methods research aims to generate a better understanding of the mental health difficulties and risk-taking behaviours among children living in residential care in England and young people’s experiences of living in these settings.

Ritika Chokhani

Ritika Chokhani is currently a PhD student in the UCL-Wellcome programme for Mental Health Science. Her research interests include understanding the mechanistic underpinnings of common mental health disorders as well as understanding the mechanisms of change in psychotherapeutic interventions. Before this, she did an MSc in Developmental Psychology (UCL) and an MPhil in Clinical Psychology (NIMHANS, India). She has also worked in different roles, including in a policy project collaborating with the Tata Institute of Social Sciences (Mumbai) to update the national guidelines for disaster mental health in India.

Maryam Javed

Maryam Javed joined University College London and Anna Freud in 2022 as a research assistant for the ReThink Programme. Her research interests are focused on global mental health and intervention effectiveness, particularly among marginalised communities such as refugees, ethnic minorities, and migrants. Maryam’s research interests have been shaped by her childhood experiences in the Middle East, moving to England in 2019, and working in various clinical settings including NHS CAMHS. Maryam was awarded the Vice-Chancellors Scholarship during her Masters of Clinical Psychology from Newcastle University. In the future, Maryam hopes to split her time between clinical and research work.

Holly Norcop

Holly Norcop graduated with a distinction in MSc in Social & Community Psychology. Her research interests include qualitative methods and action research focusing on children’s well-being. She first came to work with Anna Freud’s evaluation unit as part of the research internship scheme. Currently, she works as a freelance evaluator for creative charities nationally, exploring the impact of participatory arts on children and communities.

Nick Midgley

Nick Midgley is a child and adolescent psychotherapist, and Professor of Psychological Therapies with Children and Young People at UCL/Anna Freud, where he is director of the Child Attachment and Psychological Therapies Research Unit (ChAPTRe). His books include ‘Minding the child: mentalization-based interventions with children, young people and families’ (Routledge, 2012), ‘Time-limited mentalization-based therapy with children (MBT-C): a treatment guide’ (American Psychological Association, 2017) and ‘Therapeutic work for children with complex trauma: a three-track psychodynamic approach’ (Routledge, 2023).

Notes

1. For the purposes of this meta-synthesis, the term ‘psychoanalytic psychotherapy’ is used generically, to refer to all types of psychodynamic and psychoanalytic therapies with children and young people, including child analysis. Where studies specify what type of therapy was being examined (e.g., ‘short-term psychoanalytic psychotherapy’) those terms will be used when speaking about that particular study.